Carolyn Joyce Teuwen Learning Together, Caring Together a small scale interprofessional intervention in Health Professions education
Learning Together, Caring Together: a small scale interprofessional intervention in Health Professions education Carolyn Joyce Teuwen
ISBN: 978-94-6522-468-8 Cover & layout design: Arina van Londen | www.ridderprint.nl Printed by: Ridderprint (www.ridderprint.nl) Printing of this thesis was supported by : Noordwest Academie part of Noordwest Ziekenhuisgroep Amsterdam UMC
VRIJE UNIVERSITEIT Learning Together, Caring Together: a small scale interprofessional intervention in Health Professions education ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor of Philosophy aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. J.J.G. Geurts, volgens besluit van de decaan van de Faculteit der Geneeskunde in het openbaar te verdedigen op woensdag 3 september 2025 om 13.45 uur in de universiteit door Carolyn Joyce Teuwen geboren te Heemskerk
promotoren: prof.dr. S.M. Peerdeman prof.dr. R.A. Kusurkar copromotoren: dr. H.E.M. Daelmans prof.dr. W.H. Schreurs promotiecommissie: dr. J. Tichelaar prof.dr. R. de Vos dr. C.H.M. Latour prof.dr. F.S. Scheele prof.dr. A. van Royen
TABLE OF CONTENTS Chapter 1 General introduction 7 Chapter 2 The validation of geriatric cases for interprofessional education 23 Chapter 3 The differences in content of health care plans of medical and nursing students in interprofessional and uniprofessional education Chapter 4 How does interprofessional education influence students’ perceptions of collaboration in the clinical setting? A qualitative study Chapter 5 Geriatric interprofessional education for enhancing students’ interest in treating older people Chapter 6 Interprofessional collaboration skills and motivation one year after an interprofessional educational intervention for undergraduate medical and nursing students Chapter 7 Discussion 105 APPENDIX 121 Summary 122 Samenvatting 126 Supplementary files 130 References 137 Dankwoord 151 PHD portfolio 154 Summary of training 156 About the author 157 39 57 75 87
Chapter 1 General introduction
8 Chapter 1 The healthcare sector has become significantly more complex in recent decades due to various factors, such as an aging population, an increase in chronic conditions, and the rapid development of medical technologies and treatment methods. This complexity was further amplified by the COVID-19 pandemic, which put pressure on healthcare systems worldwide and introduced new challenges, such as managing limited resources, treating a large number of critically ill patients, and adapting to rapidly changing protocols and guidelines. Furthermore, the demographic landscape of the world is undergoing a profound transformation marked by a significant increase in the aging population. The number of people over 65 years old will double in 2050 and the proportion of people over 80 years old will increase (CBS, 2024; Hilderink & Verschuuren, 2018; Olshansky & Carnes, 2010). This demographic shift presents unique challenges to healthcare systems globally, as older adults often have complex health needs, multiple chronic conditions, and functional impairments (Balogun et al., 2015; Wolff et al., 2002), requiring a coordinated and holistic approach to their care. Throughout the world healthcare systems struggle with a shortage of health care workers and increasing costs (Boniol et al., 2022). As a result of all these profound changes, collaboration between different disciplines in healthcare has become crucial. Only by working together effectively and leveraging each other's expertise, healthcare providers can continue to deliver high-quality, efficient, and patient-centered care in this dynamic and demanding context. This practice when multiple health workers from different professional backgrounds providing comprehensive services to deliver the highest quality of care, is referred to as ‘interprofessional collaboration’ (Gilbert et al., 2010). Interprofessional collaboration can improve healthcare processes and outcomes (Flaherty & Bartels, 2019), and can also help to overcome the worldwide shortage of healthcare professionals (Wei et al., 2022). FROM INTERPROFESSIONAL COLLABORATION TO INTERPROFESSIONAL EDUCATION To collaborate interprofessionally, one needs knowledge about one’s own and others’ professions. What are the boundaries of my knowledge? What can other professions contribute to the care for this patient? How do I discuss my concerns about a patient, and how do we find a solution together, while putting the patient’s needs first? These are skills that do not come naturally to each healthcare professional and are often not explicitly present in health care education curricula. In interprofessional education, students/future healthcare professionals can be trained for these skills. Therefore, interprofessional Education (IPE) is essential to prepare students for interprofessional
9 1 General introduction collaboration (IPC) in clinical practice. In 2002, Barr defined IPE as, “when two or more professions learn with, from and about each other to improve collaborations and the quality of care” (Barr, 2002). The need for more interprofessional collaboration and education has led D'Amour and Oandasan (2005) to formulate a definition of the concept ‘interprofessionality’. They proposed a framework that identifies the processes and determinants of interprofessional education and collaboration. Interprofessionality is defined ‘as the development of a cohesive practice between professionals from different disciplines’ and extends beyond simply working together in teams to comprehend a deeper understanding and appreciation of each other's roles, expertise, and contributions. D’amour and Oandasan highlight the importance of IPC and IPE in addressing the complex and multifaceted needs of patients, particularly in healthcare settings where interprofessional collaboration is essential. Furthermore, they emphasize the need for healthcare professionals to develop collaborative skills, effective communication strategies, and a shared understanding of common goals to optimize patient care outcomes. To fully understand the processes and determinants of IPC and IPE, they have proposed the framework of ‘‘Interprofessional Education for Collaborative Patient-centred Practice (IECPCP)’’. This framework provides an overview of the linkages between IPE and IPC, and the determinants that influence IPE programs and IPC within healthcare systems. INTERPROFESSIONAL EDUCATION Interprofessional collaboration and education are interdependent and necessary to provide efficient patient centered care now and in the future. Over the past few decades, this awareness has grown. IPE initiatives and IPE research began in the 1980s as a tiny group of enthusiasts dispersed over the globe. Since then, the IPE initiatives as well as the body of literature about IPE has grown enormously (Reeves et al., 2012). The literature today describes different aspects of IPE, for example: • Different examples of IPE initiatives (Murdoch et al., 2017; Nelson et al., 2017; Reeves et al., 2013) • Readiness for IPE (AlZaabi et al., 2023; Atwa et al., 2023; O'Leary et al., 2023) • Barriers and facilitators to IPE (Bowman et al., 2023; Katoue et al., 2020; Lawlis et al., 2014) • Effectiveness of IPE (Guraya & Barr, 2018; Reeves et al., 2013; Spaulding et al., 2021)
10 Chapter 1 • Tips how to implement IPE (Bogossian et al., 2023; Shakhman et al., 2020; van Diggele et al., 2020) IPE can be offered in different forms and shapes. To give an overview of the different IPE-interventions, we categorized them as before graduation (undergraduate curriculum) vs. after graduation (continuous professional development) and inclassroom vs. in clinical practice (Table 1.1). Table 1.1: Overview and categorization of different forms of IPE In classroom setting: Simulated or assignments without patient cases With real patients / in clinical practice Undergraduate curriculum • In-classroom simulation (El-Awaisi et al., 2022; Garbee et al., 2013; Palaganas et al., 2016) • In-classroom assignments, e.g. journal reviewing assignment (Guy et al., 2022) • (In)formal reflection on educational experiences (El-Awaisi et al., 2022; Keating et al., 2023) • IPE-wards (Oosterom et al., 2019; Visser et al., 2019) • Student-led clinics (Hopkins et al., 2022) • Interprofessional clinical placements (Dean et al., 2014; Kent et al., 2017) Continuous professional development • Education initiatives for groups of health professionals working together on the same ward/department, e.g. CRM-training (Bochatay et al., 2024; Fung et al., 2015; Houze-Cerfon et al., 2019) • Reflection on clinical practice (Richard et al., 2019) • Online modules (McCabe et al., 2021) • Observation and coaching on the job, e.g. observation of interprofessional rounds, training during multidisciplinary team meetings (Carney et al., 2021; Chawla et al., 2024; Gormley et al., 2019) Undergraduate curriculum • Left upper quadrant: In Table 1.1, in the first quadrant IPE is offered to undergraduate students in a classroom setting. This can be done by simulation with standardized patients, or by fictitious paper-based cases. IPE in classroom setting with undergraduate students can also be delivered by educational forms without patient cases, for example an assignment about the pathophysiology of a disease, a literature reviewing assignment, or reflection sessions on education or clinical practice. This IPE for undergraduate students in a classroom setting is typically organized by faculty and often offered throughout the curriculum or large proportions of students within an educational program (Kent et al., 2017). • Right upper quadrant: In the undergraduate curriculum, IPE can also be offered in clinical practice. This can be done in IPE-wards, or student-led clinics. Unlike IPE in a classroom setting, IPE in clinical practice is usually not offered to all students, due to a shortage of clinical placements.
11 1 General introduction Continuous professional development • Left lower quadrant: In the context of continuous professional development, IPE can also be offered in a classroom setting. Specific training can be offered to groups of professionals. In this context, the professionals usually work together on a clinical ward, and the IPE training is offered in simulation, to practice specific clinical events, e.g. Crew Resource Management (CRM). • Right lower quadrant: IPE to professionals can also be offered in clinical practice, for example by offering coaching during interprofessional rounds or multidisciplinary team meetings. By definition, all IPE initiatives involve 2 or more professions. Nursing is the profession most often present in IPE, but also medical, pharmacy, physiotherapy, occupational therapy, midwifery and several other professions may be included. EVIDENCE OF IPE The evidence of the effectiveness of interprofessional education has increased significantly over the last ten years. Reeves et al. (2016) wrote in a review about interprofessional education and the effects on professional practice and healthcare outcomes, he described some positive effects, but groups were small and the effects could not simply be extrapolated. In this review, as well as the reviews that followed, the effects of IPE interventions were classified according to the modified Kirkpatrick levels for learner outcomes, defined by Barr et al. (2005). These levels are ordered hierarchically (Figure 1.1): • Level 1: Reaction • Level 2a: Modification of attitudes/perception • Level 2b: Acquisition of knowledge and/or skills • Level 3: Behavioural change • Level 4a: Change in organizational practice • Level 4b: Benefits to patients/clients Below we discuss the evidence of IPE on these different levels.
12 Chapter 1 Figure 1.1: Modified Kirkpatrick levels for learner outcomes, defined by Barr et al. (2005) Level 1: Reaction A review of Reeves et al. (2016) concluded that learners respond well to IPE. Rodrigues da Silva Noll Gonçalves et al. (2021) concluded the same in their review; most students have a positive perception of IPE, with different factors influencing this research finding. They also conclude that there is a need to develop more robust assessment instruments, to measure real changes in attitudes among different groups of students. Most recent studies not only focus on this first Kirkpatrick’s level, but try to measure changes in attitudes, behaviour and skills. Level 2/3: Change in attitudes, knowledge, skills, behaviour Numerous reviews have assessed the outcomes of IPE-intervention at both levels 2 and 3. Reeves et al. (2016) found that, students that who participated in an IPEintervention, reported increases in collaborative knowledge and skills. Lim and NobleJones (2018) found that pre-registration nursing students had a better understanding of professional roles, improved communication and teamwork after IPE. Riskiyana et al. (2018) describe that, in the sixteen articles included in their study, IPE improved interprofessional collaborative knowledge, skills, and behaviour based on objective measurements. Complexity of the course material, suitability of the program design, and reference to a certain level of competency were seen as important factors in the success of an IPE-program. Guraya and Barr (2018) identified a positive
13 1 General introduction impact of IPE in improving the knowledge, skills, and attitudes of students about collaborative teamwork. Spaulding et al. (2021) observed significant improvements in 17 out of the 19 studies that evaluated the attitudes towards other disciplines. There were 7 studies that assessed change in collaborative behaviour, and they all found significant improvements. Mixed results were found among the 12 studies that assessed progress of collaborative skills. Saragih et al. (2024) performed a review about the impact of interprofessional education on collaborative practice of healthcare professionals. The results showed that interprofessional education significantly improved interprofessional knowledge and attitudes towards other professionals. Level 4: Effects on patient outcomes The fourth Kirkpatrick level, effects on patient outcomes and organizational practice, seems to be the most difficult outcome to measure. In 2016, Reeves et al. (2016) stated in their review, that there is limited but increasing evidence related to changes in organizational practice and benefits to patients. Rutherford-Hemming and Lioce (2018) also found, in their review about IPE in nursing, that more studies with rigorous research designs are needed to compare outcomes to determine the effects on patient outcomes. Recently, Cadet et al. (2024) performed a scoping review, describing the evidence linking IPE interventions to improving the delivery of safe and effective patient care. The 94 papers included offered a wealth of data that demonstrated a positive relationship between IPE interventions and a number of important quality health indicators, such as mortality, length of stay, medical errors and patient satisfaction. They argue for further implementation and evaluation of IPE interventions to improve patient outcomes. A recent review of Shuyi et al. (2024) evaluated the effectiveness of interprofessional education for medical and nursing professionals and students on all four Kirkpatrick levels. They found improvements on all levels after IPE. There are gaps in the literature about IPE that can be investigated. First, most research on IPE initiatives focus on the first two or three Kirkpatrick-levels (Reeves et al., 2016). Level four is the most desirable to measure, because it can determine whether IPE has an effect on clinical outcome. When IPE is offered in undergraduate curricula, it’s challenging to measure outcomes at level four, because students generally do not share responsibility for patient care in clinical practice. And when they do, it is usually under strict supervision. Nevertheless, it is important to measure outcomes at the highest level possible, because those outcomes make a difference for the clinical care for patients.
14 Chapter 1 Second, many IPE-studies investigate the effect of interventions on IPC only with quantitative measures (Berger-Estilita et al., 2020; Fox et al., 2018; Gould et al., 2017). But how this behavioural change in IPC established by an IPE intervention has not yet been investigated. Perceptions and ideas influence behaviour (Beck & Haigh, 2014). Therefore, a behavioural change of students in clinical practice might be the result of a change in students’ perceptions and ideas. More knowledge about the effect of IPE on students’ perceptions through qualitative studies, would help to understand how IPE is effective, and can therefore help to shape powerful IPE-interventions. Third, more studies are needed that focus on a long-term change in collaborative competencies, which is the penultimate aim of IPE (Marion-Martins & Pinho, 2020; McNaughton, 2018; Reeves et al., 2016; Rodrigues da Silva Noll Goncalves et al., 2023; Spaulding et al., 2021). The focus of this dissertation is on investigating the above-mentioned gaps in the literature. This research has been conducted in the context of IPE for undergraduate medical and nursing students. The broad research question was: What is the impact, short-term and long-term, of a small-scale interprofessional education intervention on the interprofessional collaboration skills, perceptions and motivation of nursing and medical students? IPE IN GERIATRIC CARE Since a variety of disciplines are involved in geriatric care, IPE is well-matched with geriatric care education. The combination of IPE and geriatric care education has been studied together in different settings, with different aims (Brown et al., 2018; FloresSandoval et al., 2021; Gruss & Hasnain, 2021; Svensberg et al., 2021; Thompson et al., 2020). A slipstream effect of a geriatric IPE initiative, could be an increase in the number of students that are motivated for working in geriatric care. IPE programs could help motivate students to work with geriatric patients, since students are able to expand their knowledge, and deliberate with each other about geriatric problems (McManus et al., 2017). Only a few studies have investigated if IPE in geriatric care improves students’ motivation for working with older patients. These studies have been conducted without a control group and have given inconclusive results (Basran et al., 2012; McManus et al., 2017; Neils-Strunjas et al., 2020; Washington et al., 2023; Willis et al., 2023). The question whether IPE improves students’ motivation to work with older patients remains unanswered in the literature. In this thesis, we investigate this question.
15 1 General introduction IPE WITH CONSTRUCTED CASES Considering that students’ attitudes towards each other and their collaborative knowledge and skills improve after experiencing IPE, initiatives on IPE that occur in the classroom or simulation settings have a place in health professions education curricula today (Evans et al., 2019; Gough et al., 2012; Reeves et al., 2016). Combining several types of IPE initiatives makes IPE practices sustainable (Khan et al., 2016). To prepare students for IPC in the workplace, IPE can be offered in a classroom setting with the use of constructed cases (Morison & Jenkins, 2007). Using cases in this way has several advantages: it can help students practise their professional roles and responsibilities, it can facilitate clinical reasoning, and casebased education is effective for students working in pairs (Jäger et al., 2014; Kim et al., 2006; Li et al., 2019; Postma & White, 2015). These can be valuable because understanding one’s own and each other’s roles is the most important aspect of effective IPE (Reeves et al., 2016). When using cases, it is essential that they are realistic (Kim et al., 2006; Reeves et al., 2016). However, actual cases from clinical practice often need to be adapted before applying them in an educational setting or IPE because they need to: (1) meet a particular level of competence for each group, (2) simulate a clinical setting, where students of specific professions can play their own role and (3) demand the use of interprofessional collaborative competencies (Azer et al., 2012; Kim et al., 2006). Alternatively we can use constructed cases. While a few articles have described tips for constructing cases, there is a lack of literature on how to construct cases using scientifically proved methods (Azer et al., 2012; Cohen et al., 2017). Moreover, there is no literature on how to construct cases for IPE. COMPETENCIES FOR IPC With IPE, the competencies required for good interprofessional collaboration can be trained. In order to do this, it must be clear which competencies are important in IPC. In 2009, six national education groups came together to form the Interprofessional Education Collaborative (IPEC) to “promote and encourage constituent efforts that would advance substantive interprofessional learning experiences to help prepare future health professionals for enhanced team-based care of patients and improved population health outcomes.”(IPEC, 2023)
16 Chapter 1 IPEC defined the following four competency areas of interprofessional collaborative practice (Figure 1.2): • Values and Ethics: Work with team members to maintain a climate of shared values, ethical conduct, and mutual respect. • Roles and Responsibilities: Use the knowledge of one’s own role and team members’ expertise to address individual and population health outcomes. • Communication: Communicate in a responsive, responsible, respectful, and compassionate manner with team members. • Teams and Teamwork: Apply values and principles of the science of teamwork to adapt one’s own role in a variety of team settings. The definition of these competencies has been of importance to health professions education. The competencies reflect the idea that interprofessional collaborative practice is essential to providing safe, excellent, equitable and client-centered care as well as improved population health outcomes. The purpose of this set of competencies is to equip students to pursue lifelong learning and collaboration with others for enhancing health outcomes. Figure 1.2: IPEC core competencies for IPC (IPEC, 2023)
17 1 General introduction THEORETICAL FRAMEWORKS USED IN THIS THESIS Social Capital Theory Viewing the impact of an IPE-intervention through a theoretical lens can provide insights into why IPE is effective. One of the theories used to study the ‘how’ of IPE is the theory of social capital (Craig et al., 2016; Hean et al., 2013; Lee et al., 2019). Social capital theory describes how social relationships and social networks generate benefits, i.e. resources of knowledge or support, for the individuals involved in them (Bhandari & Yasunobu, 2009). These social networks are a key component in IPE and IPC (Dennick, 2012; Hean et al., 2012), since students learn ‘with, from and about’ each other. In other fields social capital is associated with several advantages such as innovation and improved health outcomes (Lee et al., 2019; Nahapiet & Ghoshal, 1998). In IPE-research social capital has been used in several case studies (Burgess et al., 2020; Craig et al., 2016; Lee et al., 2019). Research about the transfer of knowledge and experiences from IPE to IPC is needed, and maybe social capital facilitate this transfer. Based on levels of social cohesion, social capital can be divided into three forms: bonding, bridging and linking social capital (Bhandari & Yasunobu, 2009). Bonding refers to connections between people that are close and strong, such as family, close friends and neighbors. It often involves people with the same characteristics and background. Bridging social capital occurs in more distant relationships, with people who are more ‘unalike’, for example with colleagues. Linking social capital refers to ties among individuals that are not only unalike, but also have different power and social status, for example between employers and employees (Bhandari & Yasunobu, 2009). Figure 1.3 depicts all these forms of social capital.
18 Chapter 1 Figure 1.3: Three forms of social capital (adapted from Aldrich (2012)) Bonding (within networks) Bridging (between networks) Different power/social status In health care, one profession could represent the network circle in Figure 1.3 on the left and another profession the network circle on the right. Accordingly, with IPE, an increase of bridging social capital could occur. Van Oorschot et al. (2006) outline that more bridging social capital could narrow the gap between different communities, such as nurses and doctors, and that it can facilitate ‘getting ahead’. In medical practice ‘getting ahead’ can involve better medical professionals and better patient care, but also the access to and acquisition of knowledge that belongs to a different profession than your own. Evaluating IPE and its effectiveness through the lens of social capital can therefore provide valuable insights regarding how interprofessional relationships between students may affect perceptions of collaborative practice. Self-determination Theory of motivation A comprehensive framework for researching human motivation and personality is provided by Self-Determination Theory (SDT). SDT describes different kinds of motivation: amotivation, extrinsic and intrinsic motivation. In case of amotivation there is no intention to act. Extrinsic motivated behaviours are driven by external factors, such as to gain a reward or to avoid a negative experience. Extrinsic motivation has different levels of self-determination: external regulation, introjected
19 1 General introduction regulation, identified regulation and integrated regulation. Intrinsic motivation is the most self-determined motivation and makes a person carry out an activity for personal interest. SDT identifies three basic psychological needs, autonomy, relatedness and competence, that need to be fulfilled and stimulate intrinsic motivation. Figure 1.4 depicts the different states of motivation and the influence of the basic psychological needs. Figure 1.4: The Self-determination Theory (adapted from Ryan and Deci (2000)) External regulation Introjected regulation Identified regulation Intrinsic regulation Integrated regulation Relatedness Competence Autonomy More external More internal Basic psychological needs Extrinsic motivation Nonregulation Intrinsic motivation Amotivation Intrinsic motivation, integrated and identified regulation together are often referred to as ‘autonomous motivation’. Introjected and external regulation together are often referred to as ‘controlled motivation’. In this dissertation we used these concepts of ‘autonomous motivation’ and ‘controlled motivation’, since autonomous motivation is associated with more sustained change and better performance (Ryan & Deci, 2000). Thus, SDT framework can be used to study the process and effects of interprofessional education (Ganotice et al., 2023). SDT has not received a lot of attention in the context of interprofessional education. Visser et al. (2019) used SDT to study students’ motivation for interprofessional collaboration after an experience on a interprofessional education ward. They found an increase in students’ autonomous motivation for interprofessional collaboration directly after their IPE experience. Ganotice et al. (Ganotice et al., 2022; Ganotice et al., 2021) were able to explain variances in behavioural outcomes (e.g. behavioural engagement in an IPE activity) with students’ motivation. The effect of classroom based IPE on students’ motivation and the effect of this motivation on students’ longterm interprofessional collaboration skills has not yet been investigated.
20 Chapter 1 OUTLINE OF STUDIES IN THIS THESIS In response to the growing importance of IPC and the aging population worldwide, this dissertation focuses on geriatric IPE involving undergraduate nursing and medical students. Chapter 2 aims to address the fundamental question of how geriatric cases suitable for IPE in undergraduate nursing and medical education can be constructed and validated. By using consensus methods, this study seeks to construct and validate patient cases tailored to the needs of IPE in geriatric care. Chapter 3 evaluates the differences between health care plans for fictitious patient cases, made by nursing and medical students in uniprofessional versus interprofessional education settings. Specifically, the study focuses on assessing disparities in diagnostics, medication management, specialist consultations, nursing interventions, and aftercare between the two educational approaches. Chapter 4 explores how participation in IPE influences students' perceptions of collaboration in clinical practice. By examining students' experiences and attitudes towards collaboration following their exposure to IPE in a classroom setting, this study aims to shed light on the potential impact of IPE on interprofessional teamwork in clinical environments. In Chapter 5, the dissertation investigates whether participation in geriatric problembased IPE influences medical and nursing students' interest in treating older patients. Chapter 6 examines the longitudinal effects of IPE on students' motivation for interprofessional collaboration and their interprofessional collaboration skills. By assessing changes in motivation and skills up to one year after the IPE intervention, this study seeks to determine the sustainability of IPE outcomes and explore the association between motivation and collaboration skills among healthcare students.
21 1 General introduction Table 1.2: Thesis outline Research questions Chapter 2 How to construct and validate patient cases that are suitable for IPE in undergraduate nursing and medical education? Chapter 3 What are the differences between the health care plans for older patients of nursing and medical students in uniprofessional versus interprofessional education, especially in the subcategories: diagnostics, medication, consulting different specialists, nursing actions and aftercare? Chapter 4 How does IPE in a classroom setting influence students’ perceptions of collaboration in clinical practice? Chapter 5 Does geriatric problem-based interprofessional education influence medical and nursing students’ interest in treating older patients? Chapter 6 Is there a change in motivation for interprofessional collaboration up to one year after an interprofessional education intervention? Is there a change in perceived interprofessional collaboration skills up to one year after an interprofessional education intervention? Is motivation for interprofessional collaboration associated with interprofessional collaboration competence? Through a comprehensive examination geriatric IPE in undergraduate nursing and medical education, this dissertation aims to contribute to the growing body of knowledge on effective strategies for preparing healthcare professionals for collaborative practice in the care of older adults.
Chapter 2 The validation of geriatric cases for interprofessional education: A consensus method CJ Teuwen RA Kusurkar WH Schreurs HEM Daelmans SM Peerdeman This chapter was published as an article in Journal of Medical Education and Curricular Development, 2020, 7 Available online at https://doi.org/10.1177/2382120520957639
24 Chapter 2 ABSTRACT Background Case-based Interprofessional Education (IPE) can help students practise their roles and responsibilities. To construct these cases, input from experts in clinical practice is essential. Consensus between these experts can be facilitated using consensus methods. In this study, a geriatric focus for the cases was chosen because of the interprofessional nature of geriatrics and the ageing population in healthcare facilities. Methods By combining the three most commonly used consensus methods, we developed a six-step approach to validate cases for IPE. The six steps include three expert rounds (Steps 1, 3 and 5) and two rounds in which discussion points were formulated by the researcher (Steps 2 and 4). The cases were piloted with students as Step 6. Four facets of a case were included: the patient description, the complemented treatment plan, the difficulty of the case and the scoring of the treatment plan. Our educational setting required constructing four cases with increasing difficulty. Results Step 1: Five typical geriatric cases were assembled. Step 2: Similar characteristics were defined; five cases were merged into four. The four cases showed increasing difficulty levels. Step 3: The constructed cases were validated for patient description authenticity, treatment plan adequacy, difficulty and scoring of the treatment plan. Step 4: The items for further discussion were defined. Step 5: Consensus was reached for all four cases through a face-to-face discussion. Step 6: The student pilot for Case 1 showed no significant adjustments. Conclusions We developed a six-step consensus method to validate cases for IPE, and we constructed four geriatric cases based on this method. While consensus about the patient descriptions and difficulty levels was reached easily, consensus on the treatment plans was more difficult to achieve. Validation of the scoring of the treatment plan was unsuccessful. Further research on this will be conducted.
2 25 The validation of geriatric cases for IPE BACKGROUND Based on the premise that Interprofessional Education (IPE) improves Interprofessional Collaboration (IPC) in healthcare practice, numerous interprofessional initiatives have been established in healthcare centres and educational facilities around the world (Jackson et al., 2016; Oosterom et al., 2019; Reeves et al., 2016). The World Health Organization emphasizes the importance of IPE and IPC and formulates the following definitions (Gilbert et al., 2010): • ‘Interprofessional education occurs when two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes’. • ‘Collaborative practice in healthcare occurs when multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers and communities to deliver the highest quality of care across settings’. IPE can be offered in different settings. An obvious setting is the so called ‘IP training ward’, where students can collaboratively perform actual patient care. Although an IP training ward may seem ideal, it is often a logistical challenge (Jackson et al., 2016; Oosterom et al., 2019). This can result in students participating in the ward for too short a time for the training to be effective; moreover, training in this ward is timeconsuming for the trainers involved (Oosterom et al., 2019). Considering that students’ attitudes towards each other and their collaborative knowledge and skills improve after experiencing IPE, initiatives on IPE that occur in the classroom or simulation settings have a place in health professions’ curricula today (Evans et al., 2019; Gough et al., 2012; Reeves et al., 2016). Combining several types of IPE initiatives makes IPE practices sustainable (Khan et al., 2016). To prepare students for IPC, IPE can be offered in a classroom setting with the use of constructed cases (Morison & Jenkins, 2007). Using cases in this way has several advantages: it can help students practise their professional roles and responsibilities, it can facilitate clinical reasoning, and casebased education is effective for students working in pairs (Jäger et al., 2014; Kim et al., 2006; Li et al., 2019; Postma & White, 2015). These can be valuable because understanding one’s own and each other’s roles is the most important aspect of effective IPE (Reeves et al., 2016). When using cases, it is essential that they are realistic (Kim et al., 2006; Reeves et al., 2016). However, actual cases from clinical practice often need to be altered before applying them in an educational setting or IPE because they need to: (1) meet a
26 Chapter 2 particular level of competence for each group, (2) simulate a clinical setting, where students of specific professions can play their own role and (3) demand the use of interprofessional collaborative competencies (Azer et al., 2012; Kim et al., 2006). While a few articles have described tips for constructing cases, there is a lack of literature on how to construct cases using scientifically proved methods (Azer et al., 2012; Cohen et al., 2017). Moreover, there is no literature on how to construct cases for IPE. To determine the content of a constructed case, for example the symptoms, medical problems or social circumstances often seen in clinical practice, it is essential to consult with experts. However, the involvement of several experts can make it difficult to reach consensus about the content of the cases (Humphrey-Murto et al., 2017). Consensus methods can facilitate this process. The three most commonly used consensus methods are: the Delphi Technique (DT), the Nominal Group Process (NGP) and the Consensus Development Panel (CDP) (Waggoner et al., 2016). These three methods have different characteristics, which are explained in Table 1. DT is widely used for reaching consensus among the opinions of different experts (HSu & Sandford, 2007). The data are collected using a series of questionnaires, which are sent to a selected group of experts. NGP is a consensus method based on a face-to-face meeting with the experts involved (McMillan et al., 2016). During the face-to-face meeting, experts can discuss each other’s ideas about one or more problems. CDP is also based on face-to-face interaction; it was developed by the National Institutes of Health to formulate guidelines and statements. This technique allows a multidisciplinary approach of different experts; therefore, it can be useful in healthcare policy making (Waggoner et al., 2016). In a comparative study, Waggoner et al. found that none of these methods is preferred over the other; they summarised the characteristics of the different methods by reviewing the current literature (Waggoner et al., 2016). Table 2.1 presents an overview of the different aspects of the three methods (Waggoner et al., 2016).
2 27 The validation of geriatric cases for IPE Table 2.1: Aspects of the different consensus methods. DT NGP CDP a Experts in the field √ √ √ b Diverse experts √ √ √ c Every expert only once √ d Formulation of discussion points by researcher(s) √ e Number of experts 5–9 5–10 6–11 f Rounds >1 4 Var. g (Partly) open first round √ h Face-to-face meeting by experts √ √ Note: Delphi Technique: DT; Nominal Group Process: NGP; Consensus Development Panel: CDP The objective of the present study was to use consensus methods to construct and validate patient cases that are suitable for IPE in undergraduate nursing and medical education. We chose a geriatric focus for our cases because of the different professions involved in caring for geriatric patients. IPC between these different stakeholders is important for adhering to a good standard for the quality of care (Tsakitzidis et al., 2016). Furthermore while there has been a substantial increase in the number of elderly patients in the countries in northern and western Europe, few medical students are interested in working with these patients (Meiboom et al., 2015). It has been reported that geriatric IPE programs help motivate students to work with geriatric patients, since students are able to expand their knowledge, and deliberate with each other about geriatric problems (McManus et al., 2017). METHODS The six steps based on the consensus methods To reach consensus about and validate the content of the cases, we used a combination of the three consensus methods. We did this because none of the methods covered all the aspects that are relevant to the construction of cases. We chose the best aspects and the aspects that are most applicable to this research topic. Table 2.2 provides justification for these different aspects, and how and why they were implemented in our study.
28 Chapter 2 Table 2.2: Justification for the different consensus methods and an explanation for their application in this research study. DT NGP CDP Application in this study a Experts in the field √ √ √ -As diverse as possible, but within the professions of our educational setting (doctors and nurses) - Involved in caring for geriatric patients Explanation: - Diverse and most realistic viewpoints on how a patient is presented in our healthcare system b Diverse experts √ √ √ - Different settings: at home, hospitalised or at a nursing home Explanation: - Diverse and most realistic viewpoints on how a patient is presented in our healthcare system c Every expert only once √ - Different experts for each round Explanation: - Information can be checked by colleagues and subjective items will be filtered out - Workload of the experts involved will be kept to a minimum d Formulation of discussion points by researcher(s) √ - Researcher formulated discussion points Explanation: - Minimises the experts’ workload e Number of experts 5–9 5–10 6–11 2–9 per round; a total of 17 f Rounds >1 4 Var. 3 g (Partly) open first round √ - The first round consists of open questions Explanation: - Lets the experts describe their typical geriatric patient - Generates information from clinical practice without giving assumptions h Face-to-face meeting by experts √ √ - Face-to-face contact between two experts Explanation: - To reach consensus about the last discussion points Note: Delphi Technique: DT; Nominal Group Process: NGP; Consensus Development Panel: CDP
2 29 The validation of geriatric cases for IPE The cases and setting In our setting it was logistically easy to include medical and nursing students, so we focused on these two groups in this study. In future studies, other professions, e.g. physical therapy and social work, can be included following the same methodology. We constructed four cases to be used in our nursing and medical curriculum in a classroom setting, during a one-year training period. Since skills and knowledge increase over time, the four cases needed to have different levels of difficulty. To determine on which prior knowledge and competencies the cases could be built on, we consulted nursing and medical educators on the geriatric content of both curricula. The problems that were discussed needed to be recognisable and frequently occur in clinical practice. For each case, the students worked in pairs of medical students and nursing students to develop treatment plans. The students’ treatment plans were assessed by comparing them to a standard validated treatment plan formulated by the experts. Figure 2.1 presents an impression of the items that needed to be validated for each case. In the six steps, we validated: • The content of the cases (patient description and treatment plan); • The scoring (difficulty and scoring of treatment plan). Figure 2.1: Visual impression of a case Patient description History ……………….. Social circumstances ……………….. Currenthealth problem ……………….. ……………….. Etc. Treatment plan Scoring Additional investigation ……………….. 1? Medication ……………….. 1? Consults ……………….. 1? ……………….. 1? Etc. CASE 1 Difficulty score: …? Note: content: red; scoring: green
30 Chapter 2 Integral, Interdisciplinary and Medical (INTERMED) for the elderly To define the difficulty of each case, in the first round we asked the experts: What makes a case like this (not) difficult? We compared their responses with the information in the literature about the tools that measure case complexity, especially in geriatric patients. We found that INTERMED for the elderly best resembles the items named by the experts. INTERMED was developed originally to facilitate the description of case complexity for clinical and educational purposes (Huyse et al., 1999). Wild et al. (2011) stated that INTERMED for the elderly could be used to identify elderly patients in need of interdisciplinary care. The validity of the constructed cases is unknown. INTERMED delineates caring needs into four domains: biological, psychological, social and healthcare. Each domain has a maximum total score of 15. These four domains are structured based on time: history, current state and prognosis. The INTERMED for the elderly score ranges from 0 (not complex patients) to 60 (very complex patients). Based on the aspects presented in Table 2.2, we formulated six steps (Figure 2.2): • Three expert rounds (Steps 1, 3 and 5); • In between, the information is summarised by the researcher (Steps 2 and 4); • We added a pilot testing with students to assess the constructed cases (Step 6). Figure 2.2 shows what we did in each step to validate the content and scoring of each case.
2 31 The validation of geriatric cases for IPE Figure 2.2: Description of the six steps for validation of content and scoring of each case. Content Scoring Step 1: Experts round 1 Email sent to three groups of experts asking to describe: • Two typically geriatric patients; • Matching treatment plan (roughly). Open-ended question to experts: “What makes a case like this (not) difficult?” Step 2: Researcher Construction of four cases: • Similar, most frequent characteristics; • Treatment plans were complemented by information from educators and guidelines. Score every item in the treatment plan with 1 point. Score cases for difficulty (INTERMED). Step 3: Experts round 2 Nine experts: • Is the content realistic? • Is a case like this often seen in clinical practice? • Is the treatment plan adequate and complete? Scoring treatment plan: “Is assessing each item with 1 point an adequate way of scoring?” Difficulty: “How complex do you think this case is, from 0 to 60? Is this based on INTERMED or your own judgement?” Step 4: Researcher Adjustments to the cases: • Relevant, simple suggestions (e.g. layout); • Simple suggestions with relevant argument (e.g. medication doses). Two lists with items without consensus: • Primary list: all items named more than once; • Secondary list: all other items, named once. Scoring treatment plan: • Make an inventory of the comments by experts. • Select the most essential items with the educators. Difficulty: • Calculate the averages with and without INTERMED. Step 5: Experts round 3 Face-to-face discussion with two experts • Discuss all the items on the primary list.; • Items on the secondary list were only discussed/adjusted if the experts called for them spontaneously. Scoring treatment plan: “Point out the most essential items in the treatment plan” ◊ compare those to the essential items pointed out by the educators. Step 6: Pilot testing with students Case 1: three medical students and three nursing students: • How much time did you need? • Did you understand the assignment? • Do you have other suggestions? Scoring treatment plan: Score the students’ treatment plans. Difficulty: Students’ opinion: how difficult? 1–10
32 Chapter 2 RESULTS Using the six steps, we constructed and validated the content and scoring of the four cases. Consensus was achieved after Step 5. The results of each step are specified in Figure 2.3. Figure 2.3: The results of each step. Content Scoring Step 1: Experts round 1 Five Cases collected: • Two cases by two residents in geriatrics; • Two cases by one nurse specialising in geriatrics; • One case by three nurses on the geriatric care unit. Difficulty increasing aspects, according to the experts: • All geriatric cases are complex • Non-specific presentation • Patient can’t take care of him/herself • Patient is also (overloaded) caregiver for partner at home • More than one physical or cognitive problem • Limited social network • Limited mobility • Several comorbidities Step 2: Researcher Construction of four cases (four different medical problems, accumulating over time) based on one patient: • Usage of similar characteristics (e.g. medical background, social circumstances); • Two similar medical problems ◊ merged into 1onecase. Develop treatment plans for each case. All items fitted into five categories: • Additional diagnostics (e.g. scans) • Medication • Consults • Nursing actions • To-do before discharge Scoring treatment plans: Twenty items/points (least complicated case) up to 30 items/points (most complicated case) Difficulty: Aspects named by the experts in Step 1 fitted into the categories of INTERMED. Score cases for difficulty with INTERMED: 14, 28, 37, 41. Step 3: Experts round 2 Total cases: 1–4 Number of experts that answered (n=36) yes, yes if or no, to the question: Is the… Is the scoring of the treatment plan adequate? (n=36) Yes: 21 Yes if: 7 No: 8 Difficulty per case: patient description… treatment plan… INTERMED Expert, with INTERMED (n=4) Expert, without INTERMED (n=5) Realistic? Frequent? Adequate? 1 14 14 23 Yes 20 22 5 2 28 28 29 Yes if 10 10 17 3 37 34 34 No 6 4 14 4 41 40 31
2 33 The validation of geriatric cases for IPE Content Scoring Step 4: Researcher Total cases: 1–4 Patient description Treatment plan Scoring treatment plan: Four specific suggestions were given (‘score this item with 2 points’). No duplication of any item. Educators highlighted the most essential items for each treatment plan. primary list 5 10 secondary list 3 45 Step 5: Experts round 3 Total cases: 1–4 Patient description Treatment plan Scoring treatment plan: The most essential items in the treatment plan highlighted ◊ compared to the essential items of the educators ◊ no correspondence ◊ ‘one item, 1 point’. Items discussed 7 27 Items without consensus 0 0 Step 6: Pilot testing with students Feedback from the students: • Sufficient information to complete the assignment (i.e. treatment plan) • Not clear how much is expected ◊added some instructions • 30 minutes is sufficient Difficulty: Average of case 1: 4.3 out of 10 Scoring the treatment plan for case 1 (total 20 points): • Essential items were not often scored • Three medical students: 3, 5, 7 points • Three nursing students: 4, 7, 10 points
34 Chapter 2 DISCUSSION We developed a six-step process to create geriatric cases that can be used for classroom IPE. The six steps are based on the characteristics of three consensus methods (DT, NGP and CDP), so the content of the cases could be validated. We chose a geriatric focus and an interprofessional setting, but the six steps can also be used in a variety of other settings. When conducting this research study, we experienced some difficulties. First, the process was time-consuming, especially for the coordinator, i.e. the researcher. However, we see this as a one-time investment. A constructed case can be re-used in an educational setting for many years. Furthermore, this approach involved minimum effort from the experts, so they were willing to participate. In the last round, both the medical resident and the nurse reported that they found that reviewing the cases was ‘a nice thing to do, because they did it together’. During the validation process, an online questionnaire for experts can result in further distributing the workload, but that will need to be developed. Secondly, the consensus process for the case content was also difficult. The results indicate that experts may easily agree upon the content of frequently seen cases. In Step 1, several of the characteristics were similar. In Step 3 and Step 5, there were a few items that needed to be discussed. There was a lot more diversity in the experts’ opinions of the treatment plans. Almost every expert in Step 3 had a unique opinion about the items that should be included in the treatment plans, e.g. whether or not to consult an occupational therapist or to order a chest X-ray. The number of ‘secondary items’ in Step 4 demonstrates this diversity: 45 about the treatment plan versus three about the content. It was possible to score the case complexity using INTERMED for the elderly. All the experts in clinical practice scored the cases similarly. Differences were seen by the experts that scored the complexity using their own judgment, not INTERMED. Case 1 was estimated to be more difficult and Case 4 was estimated to be less difficult when INTERMED was not used in comparison to when it was used. It is possible that the experts focused on the diagnosing dilemma more heavily than when using INTERMED. For example, in Case 1, the symptoms were vague, which can make diagnosing more difficult; therefore, difficulty of Case 1 was rated higher when experts used their own judgement instead of INTERMED. In contrast, in Case 4, there was a clear description and no diagnosing dilemma, but the background, comorbidity and severity of the symptoms made it complex. This case was rated less difficult by experts’ own judgements. The literature confirms the biopsychosocial strength of the INTERMED: it focuses on social and psychological problems as much as on diagnosing dilemmas (Wild et al., 2011). Scoring based on the experts’ own judgment has not
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